SITE INFORMATION AND CORRESPONDENCE

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' GENERAL PROGRAM FILE New Change Edit (PROG3) revised 8/26/93 FACILITY I) N - FACILITY "AME Alden Park/City of Tracy/Various Residents RECORD 10 B .� -.�� `� PRIOR SWEEPS/CCMP M DAIRY: Grade A Grade B _ MiLk Dispenser Number of Containers in Multi-Head Unit FOOD: Restaurant Market Commissary _ Mobile Food _ Produce Stand _ Ice Plant Seating Capacity Scl Ft Market w/Food Prep: Y / N Temporary Food Facility _ Special Food Event _ Vending Machines _ Number of Vending units Food Vehicle Make License N Registration 0 Color HAZARDOUS WASTE: Tons Generated/Yr TIERED PERMIT Facility : CA _ CE _- PER HOUSING: Hotel/Motel No. of Units Jail/Exempt Institution Housing Abatement Employee Housing _ No. of Employees Approx Dates of Occupancy ��_ to LIQUID WASTE: Pumper Vehicle Pumper Yard Chemical Toilets _ No. Package Tx Plant _ MEDICAL WASTE: Primary Care Acute Care Skilled Nursing _ LB Generator _ Sm Ganerstor Storage (2-10) _ Storage (11-90) _ storage < 150 ) _ Transfer eta _ Ltd Hauler _ Vet Clinic RECREATIONAL HEALTH: Pool/Spa Number of Pools Out of Service Pool _ Natural Bathing Plate X_ SITE MITIGATION: Environ Assess UST/CAP _ Loc Hal Waste _ Haz Mat PPL Other Lead Agency Site _ Agency: RWQCB X DTSC NPL Site _ RR/H20 0 _ Other SOLID WASTE: Landfill Transfer Sta Recycling Fac Waste Storage Fac „„'-Agal W/Jst�>,��ea'i�yttte-_,__ SW Vehicle _ No. Durpster _ No. StetldMBry Cospbetidr..51 to - VECTOR CONTROL: Poultry Form _ Max Number of Birds Kernel s EMFeGEACY NOTIFICATION for this FACILITY and/or PROGRAM DAY NIGHT CONTACT 1 : Don 0. Culbertson/Chevron Pipe I inP Co. ( 10) 842 6930 CONTACT 2 : Bob Butler MO) 242 Aa24 t_) DESIGNATED EMPLOYEE # 684 PROGRAM ELEMENT 0 P9.60 CURRENT STATUS N OF UNITS : EPA iD N: INSPECTION CODE : �OCi BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned Omer, operator or agent of same, acknowledge that ell site and/or project specific PHS/EHD hourly charges associated with this facility or activity wilt be billed to the party identified as the BILLING PARTY on this foam. I also a tify that I have prepared this Application end that the work to be performed will be done in accordance with all applicable SA GAOUIN C Y0 nce Codes and/or Standards end State and/or Federsl lows. APPLICANT'S SIGNATURE Title: Environmental Specialist Bete: (n/Leo Z AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when opptic�ab elel 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or envirormentat/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIViSICN as soon as it is available and at the same time it is provided to me or my representative. Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check IIIRecvd BY 1 2J 234.00 234.00 RENS / / � saw /_�— ACCT - i; �' UNIT CLK �J _